Monday, August 2, 2010

Chapter Two. Health Reform in Perspective

This is chapter two in my new book Health Reform in Perspective.

How Should Physicians Respond to Health Reform?

Prologue: Nothing brings one closer to reality than being a physician. This chapter is a reality check for physicians . Realistically, how “should” physicians respond to health reform? We should fact reality rather than fleeing from it or opposing it. We should put health reform in perspective.

Last month I spoke at a high school reunion on my life as a doctor. The talk produced a standing ovation. Why did it succeed?

I suspect because my talk reviewed our shared experiences, was nonpartisan, contained self-denigrating humor, praised my classmates, and related history lessons learned. A little perspective, and a little humor, goes a long way.

Perhaps I can apply the lessons learned there to here - to how we as physicians can better connect to our primary audience - our patients- and to put health reform in its proper perspective.

History Lessons

Here is what history has taught us.

• World War II, through such advances as penicillin, sulfonamides, transfusion, life-saving battlefield treatments, and government care of 13 million soldiers, heightened public awareness of the value of regular health care, and led to later generous public support for health care research.

• Medicare and Medicare programs, introduced in 1965, have been wildly popular and wildly financial irresponsible. These entitlement programs now consume over $1 trillion, pay for 50% of health costs, and are the largest single contributor to our soaring national debt. It’s complicated. We cannot live with these programs, and we cannot without them.

• The tax code of these national entitlement programs favors tax deductibility for health benefits for employers, and imposition of third parties between payers, providers, and patients, has fostered high administrative costs, and has led to a vast $2.5 trillion medical industrial complex, now taking 17% of GDP, growing fast and uncontrollably , and eating the federal budget alive. Physicians are victims of our success.

• The treatment and successes of the medical enterprise, notably life-saving and lifestyle-saving half-way technologies - stents, bypasses, cataracts, dialysis, and joint replacements- have created public expectations for further medical wonders that cannot be met. The success of these half-way technologies has led to the cruel illusion that we can extend productive life indefinitely through technologies alone. Instead we need realistic changes in governmental altitudes above and cultural attitudes below.

• The promises of genomic therapy have yet to be fulfilled and will be unlikely to transform care into an affordable system, even though discovery of the genome dates back to 1962. Genetic engineering and stem cell research is still in its infancy, and its potentials for curing cancer and degenerative diseases are overstated. Personalized knowledge of our genetic make-ups and its applications will not lower costs and will have only marginal effects on the health system.


• Public-private collaboration is inescapable. Government now pays for half of health care. Government policies and those of the private sector need “reform.” Large social problems require large organizations and will be entrusted to those organizations, rather than to individuals. This will require fundamental changes of the status quo – reforming Medicare, how we pay and incentivize doctors and hospitals, and limiting and justifying utilization. Too much government, unfortunately, will stifle innovation.

• Liberal reform, Massachusetts-style, where the political class has been in command over the last four years, has produced a runaway “train-wreck,” leading to the highest premiums in the nation and the longest waiting times in the nation to see doctors, even though Massachusetts has the highest number of doctors per capita of any state. Replacing the current “train-wreck,” our current system of providing care across the country, with a “train-wreck” engineered by politicians, is no solution at all.

• Certain aspects of our national culture contribute to U.S. health care dysfunction and have limits – runaway expectations of perfect results based on access to technologies, belief in the absolute power of Internet-based consumer information to guide patients to good health, good doctors, and good care; tto much dependence on comparative metrics to judge doctor performance and patient outcomes, and the belief that casino-style legal oversight will somehow correct doctors abuses.

• Comparing the performance of U.S. health system to other nations is invariably misleading. The U.S. health system is a product of our culture, its affluence, its heterogeneity, its freedoms, its pockets of poverty and violence, its regional variations, its population growth secondary to exploding immigration growth, and the wants and expectations of its peoples, and cannot be reduced to simplistic comparisons.

• Reducing costs may ultimately come down to collaboration between hospitals and specialists, for that is where most current costs now lie. Reducing or stabilizing these costs may come down to bundling fees for common diseases and procedures. It may also come down to patients choosing what and what they will pay for, based on their ability to pay and the necessity of treatment to the rest of society. And, in the long term, it may come down to decentralizing care and making it more ambulatory-based and less-invasive.

• Human life, with or without universal coverage, ends in death - 99% of us will die before we reach 100, no matter what we do. Instead of unrealistic promises for extending life, we should concentrate more on comfort, relief of pain, home care, hospice care, and compassionate primary care, whatever it takes to make our final days more affordable and comfortable in familiar surroundings.

• There is always room for improvement in medical care, and we doctors should not resist that improvement or measures of that improvement.

• Repeal and Replacement of the current health reform law is unlikely, given President Obama’s power of the veto. The best we can do is to make reasonable mid-course corrections – to accept its good points and criticize its flaws and to await the decisions of voter in November 2010 and November 2012.

• Finally, we as physicians need to connect more closely with patients and to bring a sense of realism to the table. We must show we share their economic, physical, and emotional pain. We need to say that blaming physicians for shortfalls of the system is counterproductive. Paying doctors less and regulating them more will drive current and future doctors out of the system and out of caring for the sick. Universal coverage and universal access are not the same. Patients without doctors is not a tenable clinical or political solution. In the end, a balance between government and private solutions will be required, rather than more of one and less of the other.

1 comment:

Kevin said...

Excellent post, as usual. Very complete analysis of where we are, why and how to improve.